Inspection on 30/05/06 for Compass Cottage

This inspection was carried out on 30th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Compass Cottage 21/02/06

Compass Cottage 30/08/05

Compass Cottage 16/03/05

Compass Cottage 12/01/05

Compass Cottage 17/03/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Compass Cottage 90 Abbs Cross Lane Hornchurch Essex RM12 4XW Lead Inspector Mr Roger Farrell Key Unannounced Inspection 30th May 2006 11:00 Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Compass Cottage Address 90 Abbs Cross Lane Hornchurch Essex RM12 4XW 01708 443086 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Compass Residential Homes Limited Ms Joanna Martine Smith Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2006 Brief Description of the Service: Compass Cottage is a registered private care home that accommodates and supports up to three people who have learning disabilities. The two current residents moved in when the home opened in June 1996. It is less than a mile from the shops and other facilities of Hornchurch town centre. The owners have two other homes in the area, one of which, Compass Grove, is next door. All residents have single bedrooms, and share the ground floor open- plan kitchen/lounge. Historically, one manager has been responsible for this house and Compass Lodge, a short walk away further along Abbs Cross Lane, and this remains the case. She is normally based at Compass Lodge. These two homes are inspected separately, though some paperwork covers both settings, such as staff files. Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place on Tuesday 30 May 2006. The inspector spent six hours at the home, followed by an hour at Compass Lodge checking general records. The last inspection was on 21 February 2006, and was also unannounced. The ‘assistant deputy manager’ who oversees the day-to-day running of Compass Cottage was away between September 2005 and February 2006 for personal reasons, and a support worker acted up to cover this absence. She had recently returned, was now designated as the ‘deputy’, and was gradually increasing her hours. She has gained her NVQ Level 3. Jo Smith, the registered manager took a lead in dealing with the inspector’s enquiries. The deputy was also available. A third resident who had lived at this home for five years moved next door to Compass Grove three months earlier. The inspector spoke to this resident and she is very happy with the move and how she was supported with the transition. One resident was away staying with her family. The inspector appreciates the letter he received from that resident’s family commenting positively on the facilities. The other resident was present, and was again helpful in answering questions and showing the inspector his room. The inspector had the chance to speak with this person’s family at his last visit. The inspector has given the manager an overview covering the changes that are being introduced in the way care homes are monitored. This includes the frequency of visits being planned according to the homes ‘rating’, and the registered persons providing more detailed service assessments. What the service does well: This cottage style terraced house is set just back from the main Abbs Cross Road. The overall level of maintenance is adequate. Work is underway to improve the open-plan lounge/diner/kitchen. The recent attempt to change the style of this main room has not worked, and another decorative scheme will be used. The shops, transport links and other facilities of central Hornchurch are in walking distance. At this visit the home was again found to be clean. There is a good-sized garden with seating, that backs onto a brook and parkland. The service users whose home this is have good living and social skills. This means that they lead relatively independent lifestyles and can make choices about how they spend their time, both within the house and outside. The descriptions of how each person is helped with their regular activities shows a good balance between individual freedoms and knowing where some help is needed. There has been a good solution in response to some tensions that were appearing in the household group last year, with one resident moving to Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 6 the home next door. As appropriate, medication has been kept under review in consultation with the psychiatrist. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, and 5. The rating in this section remains as ‘good’. This judgement is based on the assurances that the agreed procedures would be followed in deciding who should join this household group. The assessments will cover how well a prospective resident will get on with the two established residents, and how the home can meet the new person’s support needs. Staff continue to be successful in helping residents follow a relatively independent lifestyle, including going out a lot. EVIDENCE: This group of three homes generally provide a ‘home for life’, so vacancies are rare. However, last year the inspector raised major concerns about the poor planning around an attempt to quickly move a new resident into the home next door. He asked for a much clearer policy and procedure on assessment and move-ins, including clarifying the central decision-making responsibility of the registered manager. He has been shown a series of documents that will be used as the framework in the future. These include a ‘pre-service and needs assessment’; ‘trial periods’; ‘admission procedure’; and ‘move-in checklists’ adopted from the ‘Mulberry’ series – as well as a set of NCHA forms. Part of the agreement covering the resident’s move to next door was that her place at Compass Cottage would be held for three months to make sure it worked out. That period had now passed. So far one prospective resident had visited a couple of times with his family. They decided not to proceed for reasons including the closeness to the busy road. Two other names had been Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 9 put forward. The manager repeated her assurances that the guidelines referred to above would be followed, and that compatibility with the two existing residents would be a main consideration. The manager said the homes do not accept emergency admissions. The ‘statement of purpose’ needs to be updated. There are contracts covering each person’s terms of residency on their main files, as well as the most recent version from the councils who sponsor places. Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. This group of standards are scored as ‘good’. This judgement is based on the evidence confirmed at this visit, and comments made by the residents and others. The two residents are well established in this home, both having lived there for ten years. They continue to show high levels of independence. They live active lives, and the help given by staff is well judged in ensuring that the residents follow their chosen lifestyles, which includes being out a lot. EVIDENCE: Last year the inspector acknowledged the gradual improvements made in the service users’ files, including introducing parts of a ‘Person Centred Planning’ approach. This includes a ‘My Care Plan’ section, which are still being kept upto-date. These make basic, but good comment under twelve main headings. Other sections were also being maintained, such as behavioural guidelines and contacts with social workers. Although one resident’s review had recently been cancelled, there was a good record of periodic reviews and logging contact with doctors and other health care problems. The only problem is the files have again become too bulky. The manager said new style files had been bought and a general sort out was planned. Other worthwhile sections are lists of Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 11 important contacts, holiday reports, ‘missing person’ forms, as well as detailed day-to-day notes. The manager gave an overview of each person’s current range of support needs, their contact with family and friends, and how the two residents spend their time. Last year tensions had grown within the household group, but this has been amicably resolved since one person moved next door. One resident still intends to move in with her family at some stage in the future. She continues to have a high level of independence and can say how she wants to spend her time. She no longer wants to be involved in organised groups and activities with other service users, but still likes going out regularly with staff to shops and cafes. The other resident is also saying that he has moved on from wanting to attend organised activities such as evening clubs. For over five years he attended living skills courses at a local college, but now feels he has completed all the options. He too says his preference is to use ordinary local facilities with staff. He told the inspector that staff are available to accompany him to the shops regularly and help him find the cds, dvds, and football items he collects. The deputy has always been a positive support in helping residents get out and about. There are occasions when a resident has to spend a short time at one of the other two homes when staff are out with the other person. When asked, both residents say they are okay with this arrangement – there being a general consensus amongst residents from the three homes that they like being part of this wider social circle. Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17. The quality rating in this area is ‘good’. Over the years residents have been given good guidance and support to take part in work, educational and social activities, including holiday breaks. This includes maintaining regular contact with their families. There are records covering social activities, including reports of main outings and holidays. When asked, one resident said – “My best thing is going shopping….Yes staff will come with me when I want.” EVIDENCE: A feature of this household is that service users have relatively strong independence skills. In some limited instances prompting and guidance is necessary, but in general they are confident and competent in their social abilities, but both need to be accompanied when going out. The two residents are able to exercise choice about what activities they take part in, and as stated earlier, this no longer involves organised groups. Both have good links with members of their family. One resident has an ambition to move in with her family in the future, and this is described as a viable option. Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 13 There are up-to-date daily planners listing their main activities. There are also yearly resumes of main social events, such as holiday breaks. One person is still being encouraged to attend a yoga class, but that is the only attendance at organised centres or colleges at present. There is an intention to reintroduce literacy sessions. Options for holiday breaks this year were being discussed. In general each resident prepares their own meals with some assistance from staff. There are daily menu sheets recording what each person has had to eat, covering breakfast, lunch and the evening meal. Both residents are helped to do their own food shopping, and tell the inspector that they are free to make choices. Likes and dislikes are covered in the care plans. The kitchen has a good range and variety of foodstuffs, including fresh vegetables and fruit. Residents tell the inspector that they are satisfied with the catering arrangements, and get to pick the items they like. Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21. This group of standards are rated as ‘good’. This judgement is based on the evidence covering how residents are supported with their health care needs. They are now keeping better records of contacts with doctors, dentists, opticians and so on. Better guidance is also available on medication. EVIDENCE: Assistance with personal care is largely limited to giving prompts, and at times simple assistance such as helping with hair washing. The care-plan files have a ‘my medical details’ section, with good tracking sheets covering contacts with doctors and other health care workers. Attendance at medical appointments is one area where it is necessary to accompany residents, both to help relieve anxiety and ensure understanding of information or instructions given. The GP is described as helpful, with a good attitude towards listening to residents. At the last visit one resident described how she was satisfied with the help she had received following an accident. The inspector looked at the arrangements for storing and recording medication, and these were satisfactory. A local pharmacist provides medication in blister packs, with printed administration sheets. They also provide training sessions, and all staff have to complete a competency test before being responsible for giving drugs. All staff had attended a refresher course the previous week. The inspector was shown examples where the Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 15 deputy based at The Lodge stepped in to give medication when there was a person on duty who had not yet been assessed. The supplying pharmacist also does checks of the medication arrangements at the three homes. The manager was reminded that a copy of the pharmacist’s reports needs to be kept in each home. The medication administration files have individual profiles with a photo; laminated details of the drugs being used; and instructions to follow if an error occurs – though no mistakes are known to have happened during the past year. The medication cabinet in the office was neatly arranged. Other positive points included a good log of the ‘medidose’ taken away by the resident who was staying with her family. This resident takes her tablets from the container when she is at the home. Other examples of maintaining independence include residents being accompanied to their banks, but going to the counter on their own. Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The quality rating in this section is rated as ‘good’. This judgement is based on the information available at the home; how complaints are being logged; and the good response to a suspicion about not following financial controls investigated last year by the manager and owners. EVIDENCE: Information on how to make a complaint is readily available. There is good evidence that complaints are being recorded – six relatively minor matters have been logged over recent months, and followed through. There is a file containing the required range of policies and guidance covering protection issues and how to respond. This includes a copy of ‘No Secrets’; the in-house policy and ‘Pavilion Pack’; the ‘whistle blowing’ statement, and the Havering protection guidelines. Individual staff training profiles include confirmation that they have attended a training day provided by one of the owners on recognising and responding to suspected abuse. Last October the protection procedures were followed when it was discovered that a staff member had not followed the expected steps when applying for store cards for residents. The matter was reported to the police, but no fraud was found to have taken place. The staff member was suspended and referred to the temporary POVA list. The person has not worked at the home since the irregularity was found. All staff have been given a copy of the main code of practice. When asked, a resident gave the names of who he would speak to if he had a worry, and this included the deputy, the manager, the two owners – or he said he knew he could call the inspector. Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 29 and 30. The rating under this section is ‘adequate’. The building is suitable to meet the needs of residents, but a recent attempt to improve the main communal room has not worked. The owners said they were hoping to achieve a ‘cottage appearance’ by painting the walls and reviving an earlier floor surface. This has not worked, therefore a different decorative scheme will be created. Residents’ rooms show each person’s individual tastes and interests. EVIDENCE: Communal space is an open plan lounge-diner, with a countered-off kitchen. Previous reports have consistently said that conditions are satisfactory and that residents say they are satisfied with the facilities. Indeed the relative who wrote to the inspector recently commented – “I am really pleased with the clean and pleasantly decorated cottage.” However, signs of wear were staring to show. Recently the main lounge diner had been redecorated. This room does not have good natural light, and the owners have acknowledged that this attempt to create a rustic appearance has not worked – leaving the room with darker and blotchy finishes. They have said this room will be redone, including new flooring. Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 18 All three bedrooms are above the minimum space standard. The two occupied rooms reflect the tastes and interests of each resident, and have a good range of home entertainment equipment. The bathroom is on the first floor. This has a basic decorative appearance, but was found to be clean and functional. There is an additional loo on the ground floor under the stairs. The washing machine and dryer are in the small room used as the office on the first floor. This is said not to be problematic, and the inspector was told that this arrangement has previously been seen and approved by a fire safety inspector. Neither resident need any special adaptations or mobility aids. Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. The quality rating in this section is ‘good’. Last year’s inspection reports said that the main problem was keeping staff. The main positive finding at this visit was that staff retention has improved considerably. There is an improved record of demonstrating that staff are receiving training in the core areas recent courses have included adult protection, food hygiene, fire safety and medication. There is also a clearer plan for supporting staff gain a NVQ qualification. EVIDENCE: There is an overlap between the staff that work in this home and at Compass Lodge, though only women staff work at The Cottage. The staffing complement for Compass Lodge and Compass Cottage combined is – manager; full-time group deputy (based at The Lodge); deputy (based at The Cottage); 1 full-time senior care assistant; and 5 full-time and 6 part-time care assistants, of which 4 cover night shifts. Cover in this house is 1 staff member on duty on the early and late shifts (7.30am to 10.00pm, with an afternoon handover overlap of 30 mins). Night cover is one waking person. At present this means a ratio of one staff member to two residents through the day. Current rotas show occasional ‘long-shifts’, though these were said to be voluntary, and are followed by a day off. Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 20 A year ago a headline concern was the high turnover of staff. At that time the manager’s main frustration was that the time being spent on early stage induction and subsequent training was largely being lost. The good news is that the improved retention and consistency noted in the last report is still the case. Most of the staff who cover The Cottage have now been with the company for more than eighteen months. At present there were only two care assistant post vacancies – with one person due to commence, and recruitment underway for the other. New staff only work at The Lodge under supervision until they are judged competent to be on duty alone at The Cottage. This improved stability means that the manager can proceed with a more planned strategy for training. The training profiles for established staff show that they have covered the main core areas such as food hygiene, fire safety, medication, first aid, and manual handling. The inspector has seen the training needs assessments done in supervision. The manger provided a list of those who have achieved NVQ L2 or above. And the three staff who are due to complete soon. Four staff are due to be supported start on a training scheme in September 2006. This means that they now are working towards achieving the expected quota of 50 qualified staff. Reasonably regular staff meetings are occurring, and these are now for staff from all three of the company’s homes. The manager explained how an ‘Employee of the Month’ scheme was working. The manager is good at carrying out the required range of vetting - such as getting two references, a CRB certificate, and checking permission to work. The well arranged staff files have a training profile, induction checklist and copies of course certificates. This reflects the positive steps that have been taken over the last couple of years to have records that meet the standards. Following the visit, the manager sent details of CRB checks the inspector asked to be followed through. Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. The quality rating under these headings is ‘good’. The evidence includes better records of safety checks, and how the owners carry out, and follow through unannounced checks. EVIDENCE: The manager has fifteen years experience in the care sector, eight of these in a management position. She commenced with this company in January 2001, managing the smallest of the group of three homes. She took on manager responsibilities for Compass Lodge and Compass Cottage in January 2003. Her title is now ‘Area Manager’ as she supervises the manager of Compass Grove. She has the NVQ Level 3 Award, and has recently completed the RMA qualification. The owners and manager do carry out spot-checks, including at nights, and take action where they find deficiencies. It was one of the owners who spotted the financial irregularity last October that led to the protection investigation. The owners use a three-page tick and comment ‘monthly report’ format produced by the NCHA. The owners have done a very brief five year business Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 22 plans. This lacks sufficient detail to be of much use. It mainly covers a redecoration and replacements programme that has fallen behind schedule. At announced inspections the owners have made available information from their accountants confirming the viability of the business. The inspector asked to see a range of records and certificates covering health and safety. This included tests of the battery alarms and fire drills; contractor tests of the extinguishers; electrical and gas certificates; and information on Coshh materials. These were all satisfactory. Reports of the last visits by a fire safety inspector and environmental health said conditions were fine. The last independent infection control and hygiene audit gave the home a commendable overall score of 93 . The only gap was not having a water safety certificate. At this visit the only issue raised that a resident said that his smoke alarm was giving out the low battery bleep - that he had mentioned this to staff – but there had been a delay in fitting a replacement. This was dealt wit, but indicates a quicker response is needed. Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X X 2 X Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 24 No. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 YA1 2 YA24 3 4 YA32 YA42 18(1) 23(4) 23(2) Standard Regulation 4 Requirement Update the ‘statement of purpose’, including describing the staff team and level of cover provided. Decorate the communal room, including providing adequate flooring. Support training to ensure that 50 of staff have a recognised qualification. Have available spare fire alarm batteries, ands make sure staff know how to arrange replacements. Timescale for action 14/08/06 14/08/06 31/03/07 14/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Compass Cottage DS0000027839.V296811.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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